nephrotic syndrome

 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment



Case

15 years old girl came to the opd on 7/10/2021 with chief complaints of

Bilateral lower limbs swelling since 15 days

Reduced urine output since 10 days

Abdominal distension since 5days

Facial puffiness since 3days

Dry cough since 3days

SOB at rest since 3days

Fever since 1day



History of presenting illness:

patient was apparently asymptomatic 20days back then she developed  oedema over bilateral lower limbwhich was insidious in onset gradually progressive and extended upto the thigh .it was Pitting type .no aggrevating and relieving factors
15days back she visited to hospital -1 because of oedema over legs and they  said that is a kidney problem they have given medication and it was not relieved. After she developed abdomen distension ,cough, shortness  of breath at restand she visited to our hospital
 C/O reduced urine output, abdominal distension which is generalised, insidious in onset , gradually progressive
C/O facial puffines, swelling over hands
C/Odyspnoea at rest
C/O dry non productive cough
C/Ofever not associated with chills and rigor


She was born out of a 3rd degree consanguinous marriage. She has 2 healthy  siblings. Her father expired when she was 10 years old, he was a chronic alcoholic,  according to her mother who is unsure regarding the cause of his death, she attributes it to ? Respiratory Failure and Liver failure . 
According to her mother, her father\"s elder sister had a kidney disease due to which she expired. 
Past history ;
15 days back she developed a cystic  lesion near her vagina which burst after she got it excised in a local hospital after which there was a serous discharge. 

When she was 6 years old - she experienced cough along with dyspnea and low grade fever after which she was diagnosed to have pulmonary kochs for which she used ATT for 6 months. 


 Menstrual history ;

At 12 years of age - she attained menarche 
Periods ; regular,cycle 28days/5days,2pads/day,noclots/pain
Personal history;
Diet ;mixed
Appetite; decreased
Bowel : regular,bladder ; decreased urine out put
Sleep; adequate
No addictions
Family history ; 

According to her mother, her father\"s elder sister had a kidney disease due to which she expired. 

General examination ; 
 Patient is conscious , coherent, cooperative well oriented to time ,place, person moderately built and well nourished.
Weight:55kg
Generalised edema presenet
 pallor  present, noicterus,cyanosis, clubbing, lymphadenopathy
Vitals; 
Temperature; afebrile 98.6°
Blood pressure ;120/80mmhg
Heart rate ; 102bpm
Respiratory rate;26cpm
 Systemic examination ;
CVS ;
Inspection;
Position of trachea ;midline
No visible pulsations,no raised jvp
Precordial bulge : absent
Shape of chest; bilaterally symmetrical
Apex beat ; left 5th inter costal space1cm medial to mid clavicular line
Palpation; no palpable thrills,parasternal heaves are palpable
Percussion ; 
Auscultation; S1,S2 heart sounds are heared , no added murmurs,
Respiratory system;
Inspection of upper respiratory tract;
Oral cavity ; normal
Nose; no DNS,polyp
Pharynx ; normal
Lower respiratory tract;
Position of trachea; midline
Position of Apex beat; left5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movement of chest ; normal
 
Palpation ;
Position of trachea,apical pulse is confirmed
No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub
Percussion;
Resonant note heared,no obliteration on traubes space
Auscultation;  Inspiratory crepts in bilateral IAA,ISA

Per abdomen; 
Inspection;
Shape; distended due to fluid
Umbilicus; slightly retracted and inverted
Movements ; normal
No visible pulsations or engorged veins,no visible peristalsis
Skin over abdomen ;normal
Palpation;
No organomegaly
Percussion ;
Liver; dullnote heared
No fluid thrills,shifting dullness
Auscultation;
Bowel sounds are heared

CNS; No focal neurologic deficit





On 13/10/21




Investigations:

on7/10/21

Hb - 10.9 gm/dl
TLC - 9100 cells/cumm
Platelets - 2.54 Lakhs /cumm 
MCV - 76.6
MCHC - 35.5


Peripheral smear - Normocytic normochormic 

Her blood urea here today is 206mg/dl
Serum creatinine of 2.1mg/dl
Serum albumin of 1.8mg/dl












8-10 dimorphic RBC seen
albuminuria
10-12 pus cells
12-14 epithelial cells
granular casts present 


Blood urea; elevated



Lipid profile ; hyperlipidemia

Triglycerides;elevated

HDL cholesterol;decreased

LDL cholesterol;elevated









Provisional Diagnosis :

Nephrotic syndrome    ?UTI  ?CAP


Treatment :

On7/10/21
-Head end elevation

-oxygen inhalation if spo2<92%

- inj Augmentin1.2gm/iv/bd

-injpantop40mgiv/bd

8am-4pm

-nebulisation-salbutamol 6thhourly

Budecort12thhrly

-syrup ambroxyl10ml/po/Tid

-Temp charting4thhrly

-moniter vitals

-strictI/Ocharting

-tab pcm 650mg/po/Tid

-tabcystone60mg/po/od



On 8/10/21
-Head end elevation
-oxygen inhalation if spo2<92%
- inj Augmentin1.2gm/iv/bd
-injpantop40mgiv/bd
8am-4pm
-nebulisation-salbutamol 6thhourly
Budecort12thhrly
-syrup ambroxyl10ml/po/Tid
-Temp charting4thhrly
-moniter vitals
-strictI/Ocharting
-tab pcm 650mg/po/Tid
-tabcystone60mg/po/od


On 9/10/2021

-Head end elevation
-oxygen inhalation if spo2<92%
- inj Augmentin1.2gm/iv/bd
-injpantop40mgiv/bd
8am-4pm
-nebulisation-salbutamol 6thhourly
Budecort12thhrly
-syrup ambroxyl10ml/po/Tid
-Temp charting4thhrly
-moniter vitals
-strictI/Ocharting
-tab pcm 650mg/po/Tid
-tabcystone60mg/po/od


On10/10/21
-Fluid restriction upto 1.5l/day
-salt restricted upto 2.4g/day
-Tab.pantop 40mg/po/od
-injLasix40mg/iv/BD
-TABWYSLONE60mg/po/od
-syrupAmbroxyl10ml/po/Tid
-TABpcm650mg/po/(sos)
-injaugmentin1.2gm/iv/Bd
-Temp charting4thhrlyand tepid sponging if necessary
-strict i/o charting
-Bp/pr/spo2 charting 4th hrly
-Grbs charting 12thhrly
- daily body weight monitering


On11/10/21

-Fluid restriction upto 1.5l/day
-salt restricted upto 2.4g/day
-Tab.pantop 40mg/po/od
-injLasix40mg/iv/BD
-TABWYSLONE60mg/po/od
-syrupAmbroxyl10ml/po/Tid
-TABpcm650mg/po/(sos)
-injaugmentin1.2gm/iv/Bd
-Temp charting4thhrlyand tepid sponging if necessary
-strict i/o charting
-Bp/pr/spo2 charting 4th hrly
-Grbs charting 12thhrly
- daily body weight monitering


On12/10/21
-Fluid restriction upto 1.5l/day
-salt restricted upto 2.4g/day
-Tab.pantop 40mg/po/od
-injLasix40mg/iv/BD
-TABWYSLONE60mg/po/od
-syrupAmbroxyl10ml/po/Tid
-TABpcm650mg/po/(sos)
-injaugmentin1.2gm/iv/Bd
-Temp charting4thhrlyand tepid sponging if necessary
-strict i/o charting
-Bp/pr/spo2 charting 4th hrly
-Grbs charting 12thhrly
-daily body weight monitering


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